Provider Demographics
NPI:1801841341
Name:MOON, SCOTT A (DC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:MOON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 STOCKTON HILL ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-6601
Mailing Address - Country:US
Mailing Address - Phone:928-753-1120
Mailing Address - Fax:928-753-6191
Practice Address - Street 1:1751 N STOCKTON HILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-6601
Practice Address - Country:US
Practice Address - Phone:928-753-1120
Practice Address - Fax:928-753-6191
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5153111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZDC5153Medicare ID - Type Unspecified
AZU45922Medicare UPIN